Middle East Society for Sexual Medicine

March 2013 Issue 4

In this Issue:

Pregnancy and Sexuality

Phalloplasty for the Genetic Male

Small Syndrome: Fact or Fiction 1st announcement / call for abstracts

2nd Biennial Meeting of the Middle East Society for Sexual Medicine 3 - 5 October 2013 - Cairo, Egypt

MESSM President: Amr El-Meliegy Scientific Chair: Hussein Ghanem Local Organizing Committee Chair: Ahmed El-Sakka Local Organizing Committee Members: Tarek Anis Yasser Elkhiat Amr Gadalla Mona Reda Adham Zaazaa Abdel Rahman Zahran www.messm.org

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Middle East Society for Sexual Medicine March 2013 – Issue 4

NEWSLETTER FAMILY

Abdul Aziz Baazeem Mohamed Arafa Chairman of MESSM Chief Editor Communication Committee MESSM Newsletter (Saudi Arabia) (Qatar) MD, FRCS(C) MD Assistant Professor Assistant Professor Department of Surgery Department Umm Al-Qura University. Makkah, Saudi Arabia Cairo University, Egypt

Adham Zaazaa Elham Attallah MESSM Newsletter Editor MESSM Newsletter Editor (Egypt) (Bahrain) MD MD Lecturer Consultant Family Physician Andrology Department & Clinical Sexologist Cairo University, Egypt

Ahmed Shamsodini Dr Gamal Alhadad MESSM Newsletter Editor MESSM Newsletter Editor (Qatar) (Kuwait) Consultant MD Department, MD. Andrology and Sexology Hamad Medical Corporation, Qatar MSc. Dermatology and Cosmotology Diploma of Urology Health Care Clinic - Kuwait

Musab Ahmed Abo Ghefreh Omar Farid Elgebaly MESSM Newsletter Editor MESSM Newsletter Editor (Kuwait) (Egypt) MSc of Dermatology and Veneriology Assistant lecturer of Genitourinary Surgery. Urology department, Alexandria University, Egypt. Fellow of the European Board of Urology (FEBU). 3 / 38

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Middle East Society for Sexual Medicine March 2013 – Issue 4

TABLE OF CONTENTS

Editorial 5 Letter from the President 5

Letter from the Editor 6

MESSM News 7

Review Articles 8 and Sexuality 8 Woet L. Gianotten

Phalloplasty for the genetic male 15 Abbas Khadra, Giulio Garaffa and David J. Ralph

Small Penis Syndrome: Facts and Fiction 21 Maher Zabaneh

Have you read these papers? 24

Case Reports in Sexual Medicine 31

Educational Calendar 36

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EDITORIAL

Letter from the President

Dear friends and colleagues, We are happy to announce that the Egyptian society of In our first issue for 2013, I wish you all a happy and Andrology will join MESSM in preparation for the Cairo successful year. meeting. Also the World Association of Sexology My congratulations to our eleven members who Society will be organizing a symposium during the obtained the new qualification as Fellows of the meeting. European Committee of Sexual Medicine. The qualifying exam was held by the European Society for I encourage you all to participate in our Cairo meeting Sexual Medicine for the first time ever in December, and to spread the message to your colleagues who 2012. are interested in sexual medicine. After the success of the MESSM pharmacists symposium sponsored by Lilly which was conducted in Amr El-Meliegy several Middle Eastern countries, another symposium MESSM President named ‘Men’s Health Workshop’ is about to start soon. Also sponsored by Lilly, this will be a more interactive symposium dedicated to pharmacists.

In preparation for our 2nd Biennial Meeting in Cairo on 3 – 5 October, 2013, the Scientific Committee welcomes the submission of abstracts for oral and poster presentations. All abstracts presented at the meeting will be published in the Journal of Sexual Medicine.

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EDITORIAL

Letter from the Editor

Dear colleagues, contribution from all our colleagues from Middle East Welcome to our fourth edition of MESSM newsletter. and from the whole world. We will try our best to fulfill On our second birthday we tried to make this edition all your expectations but again the success of the as interesting and beneficial as always. We have a meeting depends on every one of you. very nice review by Dr. Gianotten regarding At last, I hope all of you the best and if anyone finds a pregnancy and sexuality which is indeed a missed way to make this newsletter more beneficial, please issue in human sexuality. Another article is written by a contact me or the executive office and I am always group of highly pronounced professionals Dr. Khadra, waiting for your criticism and ideas. Dr. Garaffa and Dr. Ralph about phalloplasty in the genetic male. What is a genetic male? You will find the See you soon in Cairo. answer in the must read article. Then at last but not least Dr Zabaneh, wrote a very interesting article Mohamed Arafa regarding an issue that is consuming the minds of big Chief Editor portion of the male population, small penis syndrome. [email protected] Read about the facts and the fictions about this issue. I [email protected] am sure you will enjoy these articles as much as I did. We also tried to keep you updated with the latest studies and cases reports from different journals. I must thank the editors for their great job in this regard. MESSM 2nd meeting is approaching and all of us are very enthusiastic about it. We are waiting for the great

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MESSM NEWS

Fellowship of MJCSM: We proudly announce that 11 MESSM members have passed the exam of the fellowship of MJCSM and are now Fellows of the European Committee of Sexual Medicine. This was the first exam for the fellowship and was held in Amsterdam in December 2012.

2nd Biennial Meeting of MESSM Please be informed that due to the regional situation"2nd Biennial Meeting of MESSM" is shifted from Beirut, Lebanon to Cairo, Egypt and will be held from 3 – 5 October, 2013.

MESSM Facebook page The MESSM facebook page is now available for all MESSM members and colleagues. Please visit our page and share with us any information that will help us improve MESSM services in the future. http://www.facebook.com/pages/Middle-East-Society-for-Sexual-Medicine-MESSM/208135919197719

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REVIEW ARTICLES

Pregnancy and Sexuality

Woet L. Gianotten

MD-psychotherapist, Senior lecturer in medical sexology

The relation between sexuality and pregnancy is rather and postpartum. On the contrary, preexisting sexual complex. Without childwish, the risk of becoming problems don’t simply disappear but can later on pregnant can easily diminish sexual pleasure as long become exacerbated by the stress of caring for a as a couple doesn’t trust their contraceptive method. baby. That is even more when the baby is planned as When on the other hand, a couple decides to make a a solution to relationship problems. An unplanned baby, sexual pleasure and sexual activities usually pregnancy more easily will contribute to relationship increase. When actually pregnant, that will change dissatisfaction, whereas a by both dearly desired again, depending on many different factors. One factor pregnancy has higher chances for sexual enjoyment. is the importance of sexuality in the couple. If for However, even then, the couple may experience some instance pregnancy was the sole reason to have ambivalence to this life transition. intercourse, sex may stop as soon as the pregnancy is Couples that tried for a longer period to conceive, have established, whereas for others being pregnant less frequent intercourse during pregnancy and the terminates the fear of becoming pregnant and finally three months postpartum. allows them to fully enjoy sexuality. Sexual disturbances in the first pregnancy and after Many cultures nourish the idea that sex is only for the the birth of the first baby could become a starting point young, the healthy and the non-pregnant. Accordingly for sexual relationship problems in later life. many obstetricians never discuss anything sexual with We should be aware that sexuality and relationship their pregnant or postpartum patients, although most quality of pregnant couples and young parents are no couples continue sexual activity during pregnancy.[1-2] stable factors, but on a meta-level also influenced by A complex set of physical, emotional, existential, changing healthcare (caesarean sections), relational, social and cultural factors cause a wide socioeconomic changes (internet) and the changing range of sexual behavior changes during pregnancy roles of men.[4] and in the . There is so much variety that nearly all conditions may be considered ‘normal’, Physiological aspects although some conditions can cause worries or be the In early pregnancy, sexual desire and behavior are reason for long-term consequences. Much information influenced by disturbing symptoms like nausea and in in this text originated from several meta-analysis.[2-5] late pregnancy by backache and fatigue. Middle A higher amount of pre-pregnancy sexuality is pregnancy is less characterized by disturbing correlated with more coital activity during pregnancy symptoms, and more by hypercongestion. This

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hypercongestion is in fact the same as what happens accordingly they have more sexual desire. However, during . other women may react totally differently, with physical Outside pregnancy, volume increases with 25% disgust and no desire at all. Whereas 12% feel more during full sexual arousal. Combined with the fast attractive, 25-50% of pregnant women feel less growing breast in middle pregnancy, this can cause attractive than before.[3] pain. High arousal pain can also happen in the vaginal Men experience also a wide range of feelings on the entrance. woman’s pregnant appearance. From erotic Pregnancy hypercongestion can on the other hand fascination to repulsion and avoidance of contact. facilitate desire, lubrication and (with more Whereas corresponding reactions of both partners will sexual dreams, stronger orgasm, or several in be convenient, discordant reactions can cause real a row). disappointment. Distress due to the changing body Facial congestion gives the pregnant woman the same shape can even negatively influence the mother-baby blushing, shining appearance as happens when sexually bonding. aroused or falling in love. There are many other areas of pregnancy with The more pregnancy progresses, the more time is extensive variety with sexual impact. needed for resolution (release after hypercongestion). Some parents dearly wanted a child, others felt Later in pregnancy, resolution will not be complete, even pressure to become pregnant or got pregnant by not after orgasm. Then, prolonged sexual excitement accident. Some women enjoy and embrace the without orgasm can cause pain. pregnancy, while others encounter many problems Orgasm tends to change in the last six weeks of along the way. Some women enjoy the pregnancy. From a series of clonic contractions to one absentmindedness; others feel cheated by that. long tonic painful contraction (maybe aggravated by the Some mothers have feelings of being invaded or prostaglandins from ejaculate). For some women these hijacked, and experience that their body is taken over painful contractions seem a reason to abstain from by the baby or the gynaecologist. Especially the orgasm. autonomous woman can perceive herself as only a In the last trimester, sexuality is influenced by fatigue pregnancy, without any identity left.[4] The more the and the increasing abdominal size. Now, many presence of the baby in utero becomes obvious, the common sexual positions are no more comfortable more the relationship dynamics change. Especially in and the sexual desire of most pregnant women will be double career couples, the changing responsibilities reduced. Pregnancy can also influence . can become a topic of discussion or worry. Some women for instance masturbated frequently Approximately 9% of pregnant women will have some during pregnancy and never when not pregnant. form of depression, an additional reason for diminished sexual contact (and increased risk of Psychological and relationship aspects postnatal depression). During pregnancy intercourse and orgasm can induce fears in both partners. The most prevalent is the fear Sexual behavior aspects of harming the baby during sexual activity. Some 25- When man and woman start a pregnancy they have 50% of expectant mothers and 25% of men are afraid each an individual, but also a joint set of sexual for sex-induced in early pregnancy, and experiences and handicaps and usually also a solid later for harming the baby and causing premature structure of pre-pregnancy sexual routine. In the course labor.[3] of the pregnancy, sexual behavior and function are Pregnancy strongly changes a woman’s appearance. influenced by worries, changes in appearance, physical How attractive a pregnant women is perceived by changes and hormonal changes, all together having herself and her partner, correlates positively with coital massive emotional and existential consequences. These activity and sexual enjoyment and negatively with factors result in a great variety of sexual wishes and coital pain. The full and glowing face make behavior. With variety not only among different women, some women very aware of her attractiveness and

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but also within one woman over the various phases of baby, men usually do not express their emotions easily pregnancy. The same goes for male partners. in “female matters”. In his typical role, the man hides his What are the most common sexual patterns? worries because he is supposed to be strong and In the first trimester, there is a small group with hardly supportive. That seems loving, but prevents the any change whereas a large group has a decrease in development of real intimacy. Men, of course worry, desire and coital activity. In part of this group the because till very short ago countless women have died decrease in desire and sexual frequency continues into during childbirth. the second trimester, whereas in others the desire In the first pregnancy 11-22% of men have complaints returns to normal levels or even becomes higher, with or (gastrointestinal symptoms, depression, insomnia and without a higher need for intercourse. In part of this headaches), found especially towards the end of the group the desire stays high until childbirth, whereas in first trimester and around the time of delivery (and others the desire decreases in the third trimester. A usually not recognized as pregnancy-related). There similar pattern seems to exist for orgasmic capacity.[3] could be a hormonal cause for such ‘sympathy pains’. This wide range of sexual response, orgasm, Those men have relatively higher prolactin levels.[6] In intercourse frequency and pleasure is in some way ‘expecting men’, several hormonal levels change. They easy for the health professional. On nearly every have lower testosterone and cortisol levels and some question regarding sexual behavior in pregnancy we have higher estrogen levels. Close to childbirth cortisol can answer: “What you experience is not abnormal!” and prolactin levels increase.[7] The low testosterone Non-genital physical contact/tenderness remains level could explain the diminished sexual interest of unchanged in the first two trimesters of pregnancy and many men at the end of the second trimester, but it does decreases continuously from the sixth month of not explain the frequently found increase in masturbation pregnancy until three years postpartum. Coital activity and sexual dreams. declines slightly in the first trimester or remains levels even play a role in the father/baby constant, and declines sharply in the third trimester, relation. Men with lower testosterone and men with while coital behavior is very variable in the second higher prolactin levels respond better to a crying baby.[8] trimester. Up to the seventh month of pregnancy most Some guess that these male hormonal adaptations are couples practice intercourse. Only one third of couples caused by female pregnancy pheromones. have intercourse in the ninth month. About 10% of the women abstain from coitus once the pregnancy is What about male sexual behavior? Interest in partner confirmed.[3] sex remains mostly unchanged until the end of the Sexual positions change. The male superior position second trimester, and then decreases sharply.[3] prevails in the first trimester, female superior position Others found that 40% of males already had in the second trimester and then changing to side-by- diminished desire at the time of the first movements of side or rear entry.[3] Whereas dyspareunia was the baby. For the woman with increased desire during experienced by 12% prior to pregnancy, this increased pregnancy, diminished partner desire can be rather to 22-50% during pregnancy.[3] disappointing. Men seem to be more inhibited about Most couples stop vaginal intercourse for several sexual activity during pregnancy than women, and months around the delivery. How this will impact the women’s sexual self-acceptance seems higher.[3] couple is partly determined by the alternatives for the Male masturbation tends to remain stable throughout man. The man with sexual needs who (by custom, pregnancy and postpartum. In monogamous societies male pride or religion) cannot masturbate or be masturbation functions as a backup when intercourse masturbated will be at a loss. with the woman is ‘not available’, for instance because she is not willing, not attractive or not seen as a Male partner aspects partner, but as a mother. For men who are not used to There are many cultural differences in the role the masturbation, pregnancy can become a troublesome male has in matters of pregnancy and delivery. period. Maybe one of the explanations for the increase Whereas women express their worries about delivery or in male extramarital sex around childbirth (found in 4-

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23% of young fathers).[3] It could be also one of the rupture. Vaginal (or oral) provides much reasons for increased domestic violence in the first prostaglandins. Vaginal dilatation by the penetrating months post-partum.[9 ] penis causes oxytocin release (the ‘Ferguson reflex’) and tapping of the penis against the causes Sex and obstetrical dangers? release of prostaglandins. Some decades ago many assumed that sex was The later stages of the delivery can also be influenced harmful. From the 1980’s, research showed that in the by aspects of the sexual repertoire. Genital (‘sexual’) healthy pregnancy sex does harm neither mother nor stimulation of the vaginal entrance raises the pain baby.[3] threshold by which the delivery can continue smoothly. Sometimes, sexual behavior can be hazardous: This is routinely applied in some cultures.  After due to uterine malformation or Depending on the partner-relation, the emotional fibroids no intercourse and orgasm in the first preparation, the setting and the course of the process, trimester. the delivery can be experienced as a positive (even  After pregnancy loss because of too wide cervix erotic) experience with elation during the immediate no intercourse and orgasm till corrected postbirth period. But it can also be experienced as a  In third trimester bleeding, prematurely ruptured negative (even traumatic) experience. membranes or signs of threatening premature Routine episiotomy (sometimes applied ‘for sexual labor no intercourse and orgasm reasons’) does not prevent damage to the pelvic floor [14]  Ruptured membranes in term pregnancy or and causes more dyspareunia. After C-section advanced cervical dilatation no penetration, but women resume intercourse somewhat earlier than orgasm is allowed. after vaginal delivery, but they have far more dyspareunia than after vaginal delivery with an intact When there are no irregularities, intercourse during late perineum. Other research showed that women with pregnancy is associated with a reduced risk of preterm primary C-section started earlier and had better FSFI [15] delivery and less preterm delivery was also found with scores at first intercourse. recent female orgasm.[10 ] However, when harboring trichomonas, mycoplasma hominis or bacterial vaginosis, frequent intercourse was Like the genitals, the female breasts have more than associated with a higher risk for preterm delivery.[11] one function. Well-succeeded lactation is an excellent Preventive advice? In the healthy pregnant woman way to optimize the long-term mother/child bond. there is no objection to sex (including intercourse), -suckling causes oxytocin release. In the first vaginal infections should be prevented and in the later weeks after delivery this lactation oxytocin-release stage of pregnancy the male superior position is better helps the uterus to (painfully) contract and return to replaced by positions with less pressure on the woman’s normal size. At a later stage the effect can be different. abdomen.[12 ] In own retrospective research we found that the in one third of women caused Sex and delivery sensations of sexual excitement, 71% had pleasurable There is little research on the question, whether sex contractions and 8% had experienced orgasm [16] accidentally (or purposely) can induce labor.[13] Sex during/due to breast-feeding. can start the process of delivery, although this will not In the months of breastfeeding a baby, the oxytocin of happen in a healthy pregnancy until full-term. What high sexual arousal or orgasm can cause milk are then possible eliciting factors? expression (a pleasure for some men, a nuisance for Prostaglandins and oxytocin, used to induce labor, are others). This dual function of the breasts, food supply also released during sex and accordingly can start the and sensitive sexual organ, can be challenging for delivery. Oxytocin is released after nipple/ breast both partners. Whereas confusing for some women, stimulation and after orgasm. Orgasm gives strong others can perfectly integrate this mix of maternal and uterine contractions, by which the membranes can erotic functions.

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The long-term consequences of lactation usually are men reported having had no sexual problems negative for sexuality. Next to disturbed sleep and postpartum. In the long run the sexual relationships of intense exhaustion, breast-feeding is accompanied by at least one-third of the couples worsens, being most hormonal changes with high levels of prolactin (low pronounced 3-4 years after birth.[3] sexual desire), low levels of estrogen (vaginal With lactation finished and the pelvic floor back in dryness and atrophy, soreness, and subsequently shape, some women experience intercourse and dyspareunia), and low levels of androgens (less orgasm more intensely than before. About one-fourth sexual desire, less arousability and more fatigue). of the mothers report such intensification of their Breastfeeding duration is the important factor. Women sexual lives after giving birth. who breastfeed for a longer period usually resume intercourse at a later time, are less sexually interested, Can post-partum sexual disturbances be prevented? suffer more often from coital pain, and enjoy Antenatal perineal massage reduces the likelihood of intercourse less.[3] perineal trauma, whereas postnatal pelvic floor Cessation of breast-feeding (‘weaning’) has several exercises can alleviate the soreness at the vaginal positive effects. Two weeks after weaning fatigue and entrance. The enhanced circulation of sexual arousal mood improve, after three weeks the sexual activity will cause quicker healing of and restoration of improves and after four weeks the frequency of entrance elasticity. Superficial wounds heal easier by intercourse, but no effect was found on sexual blow-drying with cool air and gently massaging the responsiveness or orgasm.[17] entrance with oil. With such massage, the woman can repossess her vulva and readapt to pleasurable Aspects of sexuality postpartum sensations. In sexuality and specially in pregnancy we have to be Most important is not having painful sex, which in this aware of the normative risks of data. For instance on period usually means ‘no penetration!’. Before the time of resuming coital activity. Whereas the delivery, couples that are not (yet) used to intimate average time is seven weeks postpartum, some solo or mutual masturbation could be encouraged to couples start with pleasure after 3 weeks (and some invest in such scenarios. women do so without pleasure), but 11% didn’t even start after 6 months.[3] Average doesn’t mean very Transition to parenthood much! Childbirth is a major rite of passage with much joy for Recent research in the Western World showed that all three parties involved, but also with many hassles after delivery many women start by giving oral sex to for woman and man. The new parents experience their partner, followed by engaging in masturbation profound positive and negative changes in their and only then intercourse. Women's postpartum lifestyle, their priorities and their relationship. Childbirth sexual desire seems especially influenced by the is a welcome into the world of parents, but perceptions of their partner's postpartum sexual simultaneously a farewell to independence and needs, even more than by the physical factors of birth freedom. The arrival of the first baby leaves most trauma and breastfeeding.[18] mothers and fathers with a ‘generalized sense of loss’. From a pure physical perspective, recovery from birth In spite of all available information, both partners are is a slow process. In the first 6-8 weeks and during totally confused by the existential changes in self and breast-feeding sexual arousability is reduced, the relationship. With good luck, this period will fuel the vaginal walls are thinner, and orgasms are less couple’s intimacy and closeness, with bad luck it will intense. With a too pushing male and/or a too adapting boost depression, long-lasting stress, domestic woman this can lead to sexual disturbances, especially violence and other marital problems. dyspareunia. Whereas men usually can separate parenthood and In UK research, 83% of women experienced sexual partnership, these elements are more intertwined in problems after three months and 64% after six women. Physically and emotionally, a woman needs months.[19] Only 14% of the women and 12% of the roughly one year before she has consolidated her

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identity as a mother and before she regains a grip on childbirth: a metacontent analysis of 59 studies. J her body and life (a solid argument not to become Psychosom Res 1999;47:27-49. pregnant again within one year). Her impaired physical 4. Pacey S. Couples and the first baby: responding to condition, her mental state directed towards the baby, parents‘ sexual and relationship problems. Sex and her disturbed sleep are no good conditions to Relationship Ther, 2004;19:223-46. have sex. Whereas young fathers are also exhausted, 5. Burke YZ, et al. Changes in sexual function in they can disappear to work or the outside world. relation to pregnancy and the postpartum. In: Porst Besides, sex is for part of the men a way to recharge H, Reisman Y. (eds). The ESSM Syllabus of Sexual their physical and emotional batteries. Medicine. 2012;977-88. For relationships, three is indeed an unfortunate 6. Storey AE, et al. Hormonal correlates of paternal number, and the new triad disrupts the former couple responsiveness in new and expectant fathers. Evol bond. The baby getting full attention can make the Hum Behav, 2000;21:79-95. man jealous, and the man’s disappearing to job and outer world can make the woman jealous. 7. Berg SJ, Wynne-Edwards KE. Changes in Birth indeed can be “uncoupling”. The less a couple testosterone, cortisol, and estradiol levels in men can handle this tiresome and troublesome phase, the becoming fathers. Mayo Clin Proc, 2001;76,582-92. more risk there is for a crying baby, parental 8. Fleming AS, et al. Testosterone and prolactin are resentment and domestic violence. associated with emotional responses to infant cries Evolving from partners to parents can be very in new fathers. Horm Behav, 2000;42:399-413. stressful, but at the same time very satisfying. In 9. Harrykissoon SD, et al. Prevalence and patterns of 40-70% of couples there is a drop in marital quality, intimate partner violence among adolescent and marital conflict strongly increases, There is a mothers during the postpartum period. Arch Pediatr sharp decrease in lover’s talk and sex, but usually also Adolesc Med, 2002;156:325-30. [4] much increase in joy and pleasure with the baby. 10. Sayle AE, et al. Sexual activity during late pregnancy and risk of preterm delivery. Obstet Epilogue Gynecol, 2001;97:283-9. Most obstetric professionals in the Western and Middle 11. Read JS, Klebanoff MA. during Eastern World don’t address sexuality and as such pregnancy and preterm delivery: Effects on vaginal miss a valuable opportunity for education and microorganisms. Am J Obstet Gynecol, prevention.[1,3] 1993;168:514-9. Woman and couple have many sexual insecurities and worries. And obstetric care is characterized by 12. Ekwo EE, et al. Coitus in late pregnancy: Risk of frequent visits and a close bond between professional preterm rupture of amniotic sac membranes. Am J and patient. Isn’t that a real challenge for the Obstet Gynecol, 1993;68:22-31. improvement and maintenance of sexual health? 13. Kavanagh J, et al. Sexual intercourse for cervical ripening and induction of labor. Cochrane Database Syst Rev, 2001;2:CD003093 14. Hartmann K, et al. Outcomes of routine episiotomy: a systematic review. JAMA 2005;293:2141-8. References 15. Safarinejad MR, et al The effect of the mode of 1. Auwad WA, Hagi SK. Female : delivery on the quality of life, sexual function, and what Arab gynecologists think and know. Int sexual satisfaction in primiparous women and their Urogynecol J. 2012;23:919-27. husbands. J Sex Med. 2009;6:1645-67. 2. Serati M, et al. Female sexual function during 16. Gianotten WL. Pregnancy and sexuality. In: Tepper pregnancy and after childbirth. J Sex Med MS, Owens AF (Vol. Eds.), Sex, Love and 2010;7:2782-90. Psychology: Sexual Health, Vol 2, Physical 3. Sydow, K von. Sexuality during pregnancy and after Foundations, Westport: Praeger. 2007:167-96.

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17. Forster C, et al. Psychological and sexual changes 2012;9:2330-41 after the cessation of breast-feeding. Obstet 19. Barrett G, et al. Women's sexual health after Gynecol, 1994;84:872-6. childbirth. BJOG; 2000;107:186-95. 18. Hipp LE, et al Exploring Women's Postpartum Sexuality: Social, Psychological, Relational, and Birth-Related Contextual Factors. J Sex Med,

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REVIEW ARTICLES

Phalloplasty for the Genetic Male

Abbas Khadra 2, Giulio Garaffa 1 and David J. Ralph 1

1 St Peter’s Andrology Centre and The Institute Of Urology, London, UK  The Urology Centre, Broomfield Hospital, Chelmsford, Essex, UK and Whipps Cross University Hospital, London, UK 2 Department of Urology, Clemanceau Medical Centre, Beirut, Lebanon.

Abstract malformations due to the abnormal development of the Background: The goal of total phallic reconstruction in cloacal membrane, which causes a midline defect in the genetic male is the creation of a sensate and the lower abdominal wall, a large defect in the anterior cosmetically acceptable phallus with an incorporated bladder wall and anomalies of the external genitalia neo-urethra that allows the patient to void while that may vary significantly in severity among patients. standing, engage in penetrative sexual intercourse In the most extreme cases the arrested development with confidence and ejaculate in the . of the cloacal membrane leads to urethral and rectal openings all sharing a common external orifice. Introduction In the male, external genitalia abnormalities include Indications for phalloplasty in the genetic male are short penis and epispadias. As the crura are inserted bladder exstrophy, micropenis, , penectomy for on the caudal aspect of the ischiopubic branches, carcinoma, traumatic amputation and severe corporeal which are laterally displaced, the corpora cavernosa contracture following explantation of infected penile only fuse at the distal portion of the shaft; the result is prosthesis or secondary to refractory ischemic a wedge shaped short penis (1-3). . Surgical treatment in patients with bladder and cloacal Epispadias and bladder exstrophy can be defined as exstrophy and micropenis- epispadias is a complex congenital malformations of the external genitalia and multi-stage procedure involving bladder closure with bladder in which there is failure or blockage of the pelvic osteotomy in the first days of life, followed by normal development of the dorsal surface of the penis, penile reconstruction during the second year and a abdomen and anterior bladder wall. The genital defect cervicoplasty at age 4- 5 years to improve urinary in male patients, also known as micropenis and continence. epispadias, causes major functional and psychological Genital reconstruction in patients with micropenis- problems (1). epispadias and bladder exstrophy remains a challenge, as the goals of surgery are an acceptable Bladder exstrophy is a rare entity with an estimated cosmetic and functional result with the restoration of incidence of 1/30,000 live births with a male to female sufficient penile length for successful penetrative ratio of 2/1 and represents a wide spectrum of

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sexual intercourse. combined with the use of protective torso armour, that The majority of techniques of penile lengthening has led to survival of soldiers with increasingly severe involve mobilization of the corpora cavernosa and skin pelvic and genital organ injury. The surgical treatment coverage with local flaps. Unfortunately these of penile amputation involves microsurgical techniques are associated with a significant risk of reimplantation of the penis only if the amputated part is neurovascular bundle damage with consequent loss of adequately preserved. Otherwise the remaining stump sensation and of blood supply and lead to the is tailored and prepared for a delayed penile formation of short broad , inadequate for reconstruction (19- 20). penetrative sexual intercourse in almost 50% of cases Also patients who have developed severe penile (1-8). shortening and corporeal fibrosis following repeated Micropenis, defined as a penis with as stretched length explantation of infected penile prosthesis or due to of less than 7 cm, can be idiopathic in nature or refractory ischemic priapism may be candidates for secondary to primary testicular failure, total phallic reconstruction (21). hypogonadothropic , defects in testosterone action or developmental anomalies (9). Phalloplasty techniques Penile agenesis or aphallia is an even more rare Due to the unique anatomy of the penis, penile malformation and is reported to occur in 1 in preservation should always be attempted leaving total 30,000,000 births. Historically, gender reassignment phallic reconstruction as last resort. Therefore, was considered to be the most appropriate choice for patients who have an adequate penile length following these patients; however, although adequate cosmetic partial amputation of the penis should initially be and functional outcomes have been reported, in a long offered conservative management such as division of term follow-up the majority of patients demonstrated a the suspensory ligament or excision of the suprapubic marked male psychological and psychosexual fat pad. Patients presenting with severely contracted development. Therefore patients with aphallia should corpora cavernosa following repeated explantation of be raised as males and offered total phallic infected penile prosthesis should instead be offered reconstruction, ideally during (10, 11). simultaneous total corporeal reconstruction with the Squamous cell carcinoma of the penis (SCC) use of acellular matrix grafts and penile prosthesis represents a rare malignancy in Europe and USA, with implantation as this technique yields good results in an incidence of less than 1 in 100,000. The treatment expert hands (21). of SCC was historically based on partial or total penile Total phallic reconstruction should be offered only if all amputation with formation of a perineal urethrostomy conservative measures fail and the patient is not and closure of the penile stump with local skin flaps. capable to resume penetrative sexual intercourse, to These operations were based on the understanding void while standing and to ejaculate inside the vagina, that a 2 cm macroscopic margin is necessary for or in presence of severe psychological distress. adequate oncological control (12- 15) and resulted in a The complexity of the anatomy and physiology of the significant loss in sexual function. Patient satisfaction penis and the fact that there is no good substitute for with their overall sexual life is less than 34% following the unique erectile tissue of the corpora represent the penile amputation for carcinoma and therefore these main obstacles for the reconstructive surgeon and patients represent the ideal candidates for total phallic despite a variety of surgical techniques described in reconstruction (16- 18). the literature, none fulfil all the ideal criteria and The real incidence of traumatic genital injuries has not currently universally accepted as ideal method (22- been determined, however in civilian centres it is 24). expected to be low and that is the reason why most The choice of the reconstructive technique should be case series span many years and include relatively tailored on patient’s expectations, body habitus and small numbers of patients. The scenario changes previous surgical procedures since thigh and forearm completely in the battlefield; this is consequence of the free flaps are associated with poor cosmetic result in massive destruction caused by fragmentation devices obese patients due to the excessive thickness of the

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adipose layer and transverse lower abdominal scars as in patients with micropenis or aphallia the may contraindicate the use of infraumbilical flaps. Also procedure is relatively easier as the abdomen and patients’ comorbidities must be taken into account groins are usually relatively intact and therefore the since common cardiovascular risk factors such radial artery can be anastomosed to the inferior , hypertension, dyslipidaemia, obesity and epigastric, while the venous drainage from the flap cigarette smoke are associated with high risk of veins is guaranteed by the anastomosis with the vascular complications and therefore represent relative branches of the long saphenous vein. contraindication to the use of free flaps. The technique is slightly more complex in patients who Patients must be fully counselled about the pros and have undergone previous amputation for carcinoma; cons of each type of phalloplasty and must have although the proximal urethral stump is almost always reasonable expectations. Patients desired goals in readily available for primary anastomosis to the phallic terms of size, sensation, sexual and voiding function urethra and the epigastric arteries are usually intact, also play an important role in the selection of the type the venous drainage may represent a challenge. of flap as sensation and a patent neo-urethra can be In particular, patients who have undergone bilateral achieved only with some techniques. Finally, donor radical lymph node dissection of the groin may have site morbidity as well as the number of surgical stages had the saphenous vein removed en block with the necessary to complete the phalloplasty must be taken lymphnodes and therefore the flap veins are usually into consideration. anastomosed with the dorsal vein of the penis, with the After many disappointing attempts with the use of pampiniform plexus, or directly with the femoral vein infraumbilical flaps and musculocutaneous thigh flaps (30). based on the gracilis muscle, the advent of The complexity of the reconstruction is highest in microsurgical techniques has led to a new era for total patients with bladder and cloacal exstrophy and phallic reconstruction (25). Although no controlled micropenis- epispadias or who have experienced prospective randomized studies are available to traumatic amputation. The reason being they have confirm that the radial artery free flap phalloplasty already undergone multiple previous reconstructive (RAFF) is the best technique available, most Authors procedures and frequently present with severe scarred consider that it is extremely reliable and yields abdomen, groins and limbs. excellent cosmetic and functional results in very In particular, patients with bladder and cloacal experienced hands (26- 34). This multi stage exstrophy and micropenis- epispadias have poor or procedure involves the creation of ‘a tube within a absent epigastric arteries, either due to congenital tube’ using forearm skin with the urethra fashioned defect or as a consequence of the previous multiple from the non-hair bearing area and the whole flap reconstructive procedures. based on the radial artery. Sensation is maintained Furthermore, the urethra, which had been due to the coaptation of the antebrachial nerves to the reconstructed with local flaps more than 10 years dorsal nerve of the penis and to the iliohypogastric and before and is not used for micturition, tends to be ilioinguinal nerves. contracted and inadequate for primary anastomosis to The most feared is acute thrombosis of the phallic neourethra. Although the majority of these the microsurgical anastomosis; this complication, if not patients voids through a Mitrofanoff or Montie type of identified and managed immediately leads invariably to continent urinary diversion and have had their bladder the loss of the phallus. Although urethral complications neck closed, anastomosis of the penile urethra with such as strictures and fistulas can occur in around the phallic one is paramount to guarantee ejaculation 30% of cases, correction is almost always possible from the tip of the phallus. and up to 99% of patients have been reported to be In patients with inadequate or absent epigastric artery, able to void standing from the tip of the phallus after the radial artery is usually anastomosed to the revision surgery (30). superficial femoral artery with the interposition of a The RAFF has been widely used to create a phallus in vein graft, which is usually harvested from the long female to male transsexuals. In these patients, as well saphenous vein. As this procedure requires an extra

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microsurgical anastomosis and therefore longer Various authors, in order to improve cosmesis and operating time, patients are at higher risk of reduce the risk of urethral complications, have postoperative complications such as thrombosis of the described modifications of the RAFF design. anastomosis. In particular, the shape and dimensions of the flap In patients who have undergone total phallic should be tailored on the size of the arm and the reconstruction with the RAFF following amputation for length of the urethral and penile stump present. carcinoma overall satisfaction can be as high as 97% If the original glans is present, it is usually left exposed with phallic sensation present in up to 86% of cases at the base of the phallus, as the neurovascular bundle (30). Satisfaction rate is expected to be lower in is not long enough to reach the tip of the phallus. patients with bladder and cloacal exstrophy and Alternatively, the neurovascular bundle can be divided micropenis- epispadias or who have experienced and the glans transferred with microsurgical technique traumatic amputation, as reconstruction is technically to the distal aspect of the RAFF in order to guarantee more challenging and therefore complications rate is superior cosmesis and sensation. In a series of 27 higher. In particular, strictures and fistulas at the level patients, after a median follow up of 10.3 years, Cheng of the anastomosis between the penile and phallic et Al. reported that all flaps had survived and that the urethra are more common in patients with bladder and sensation of the transposed glans was similar to the cloacal exstrophy and micropenis- epispadias, as the one assessed preoperatively (36). previously reconstructed penile urethra tends to have The main drawback of RAFF is donor site morbidity; a poor blood supply. although this can be dramatically reduced by adequate Implantation of an erectile device to guarantee the preparation of the donor site for grafting and with the rigidity necessary for penetrative sexual intercourse is use of hair bearing FTG instead of their split thickness usually carried out at least one year after the creation counterpart, the resulting represents a stigma and of the phalloplasty when phallic sensation is likely to can be poorly accepted by patients. have developed. Despite free osteocutaneous fibular flaps (OFF), As phalluses lack tunica albuginea, penile prosthesis anterolateral thigh flaps (ALT), latissimus dorsi flap need to be housed in a synthetic sheath, usually (LDF) and upper arm flaps have been introduced in Goretex or Dacron, in order to guarantee anchoring to order to minimize donor site morbidity, they are the pubic bone and to prevent distal extrusion. associated with poorer cosmetic results than the RAFF Frequently, patients who have undergone amputation phalloplasty, and usually do not allow the creation of a for carcinoma or trauma present with intact proximal neourethra with the tube within a tube technique (37- corpora and therefore do not require a proximal 41). synthetic sheath to be fitted on the rear aspect of the Therefore, patients who wish to void from the tip of the cylinders to guarantee their fixation to the pubic bone. phallus but do not accept a wide scar on the donor Due to the absence of the tunica albuginea and the forearm can be offered the incorporation of a radial necessity to use synthetic materials to house the artery based free flap urethra (RAFFU) in a phallus cylinders, complication such as infection of the device, previously fashioned with an infraumbilical flap. As erosion and mechanical failure are common in patients previous abdominal scars are a contraindication to the with phalloplasty. In a recent series of 129 patients use of infraumbilical flaps, this technique cannot be with phalloplasty who have undergone implantation of offered to patients with bladder and cloacal exstrophy an erectile device, infection rate, erosion rate and and micropenis- epispadias or who have undergone mechanical failure of the device were respectively extensive abdominal surgery. 11.9, 8.1 and 22.2% and revision was necessary in This technique is easily reproducible in experienced 41% of cases. Overall, after a median follow up of 30.3 hands and yields excellent cosmetic and functional months, up to 60% of patients had a normally results with all patients able to void standing from the functioning penile prosthesis and were able to cycle tip of the phallus after revision surgery. Since the flap the device (35). required is only a 4 cm wide, the resulting scar can be

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easily masked and therefore is more acceptable by the adolescence. ScientificWorldJournal 2011; 11: patients (42). 614- 623 10. De Castro R, Merlini E, Rigamonti W, Macedo A. Conclusions Phalloplasty and urethroplasty in children with Total phallic reconstruction should always be offered penile agenesis; preliminary report. J Urol 2007; to patients with penile inadequacy in order to allow 177: 1112- 1117 them to void standing and engage in penetrative 11. Reiner WG, Kropp BP. A 7 years experience of sexual intercourse; failure to do so will inevitably lead genetic males with severe phallic inadequacy to severe psychological distress. Although no assigned female. J Urol 2004; 172: 2395 randomized controlled studies are available, various 12. Smith Y, Hadway P, Biedrzycki O, Perry MJA, Authors consider that the RAFF phalloplasty yields Corbishley C, Watkin NA. Reconstructive surgery superior cosmetic and functional results. However, for invasive squamous cell carcinoma of the glans patients must be warned that multiple surgical stages penis. Eur Urol 2007; 52: 1179- 1185 are required and that revision rate can be high. 13. Morelli G, Pagni R, Mariani C, Menchini Fabris F, Minervini R, Minervini A. Glansectomy with split- References thickness skin graft for the treatment of penile 1. Woodhouse CR, Kellett MJ. Anatomy of the penis carcinoma. Int J Imp Res 2009; 21: 311-314 and its deformities in exstrophy and epispadias. J 14. Pizzocaro G, Algaba F, Horenblas S, Solsona E, Urol 1984; 132: 1122- 1124 Tana S, Van Der Poel H, Watkin NA. EAU penile 2. Vortsman B, Horton CE, Winslow BH. Repair of cancer guidelines. Eur Urol 2010; 57: 1002- 1012 secondary genital deformities of epispadias/ 15. Solsona E, Bahl A, Brandes SB, Dickerson D, exstrophy. Clin Plast Surg 1988; 15: 381-391 Puras-Baez A, Van Poppel H, Watkin NA. New 3. Varygin V, Bertonas S, Gurskas P, Karmanovas developments in the treatment of localized penile V, Strupas S, Zimanaite O, Verkauskas G. cancer. J Urol 2010; 76 (suppl 2A): s36- s42 Cloacal exstrophy: case report and literature 16. Garaffa G, Raheem AM, Christopher AN, Ralph review. Medicina (Kaunas) 2011; 47 (12): 682- DJ. Total phallic reconstruction following 685 amputation for carcinoma. BJU Int 2009; 104 (6): 4. Mitchell ME, Bagli DJ. Complete penile 852- 856 disassembly for epispadias repair: the Mitchell 17. Romero FR, Romero KR, Mattos MA, Garcia CR, technique. J Urol 1996; 155: 300- 304 Fernandez Rde C, Perez MD. Quality of life after 5. Hinman F Jr. A method of lengthening and partial penectomy for . Urology repairing the penis in exstrophy of the bladder. J 2005; 66(6): 1292-5 Urol 1958; 79: 237- 241 18. D’Ancona CA, Botega BJ, De Moraes C, Lavoura NS Jr, Santos JK, Rodrigues Netto N Jr. Quality 6. Edgerton MT, Gillenwater JK. A new surgical of life after partial penectomy for penile technique for phalloplasty in patients with carcinoma. Urology 1997; 50 (4): 593-6 exstrophy of the bladder. Plast Reconstr Surg 19. Wessels H, Long L. Penile and genital injuries. 1986; 78: 399- 410 Urol Clin N Am 2006; 33: 117-126 7. Gearhart JP, Leonard MP, Burgers JK, Jeffs RD. 20. Ralph DJ, Gonzalez-Cadavid N, Mirone V, The Cantwell- Ransley technique for repair of Perovic S, Sohn M, Usta M, Levine L. Trauma, epispadias. J Urol 1992; 148; 851- 854 gender reassignment and penile reconstruction. J 8. Reiner WG, Gearhart JP, Jeffs R. Psychosexual Sex Med 2010; 7: 1657- 1667 dysfunction in males with genital anomalies: late 21. Sansalone S, Garaffa G, Djinovic R, Antonini G, adolescence, Tanner stages IV to VI. J Am Acad Vespasiani G, Ieria FP, Cimino S, Loreto C, Ralph Child Adolesc Psychiatry 1999; 38: 865- 872 DJ. Simultaneous total corporal reconstruction 9. Wood D, Woodhouse C. Penile anomalies in and penile prosthesis implantation in patients with

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and severe fibrosis of the 33. Doornaert M, Hoebeke P, Ceulemans P, Tsjoen corpora cavernosa. J Sex Med 2012 (in press) G, Heylens G, Monstrey S. Penile reconstruction 22. Bogoras N. Uber die volle plastische with the radial forearm flap: an update. Handchir wiederherstellung eines zum Koitus fahigen Penis Mikrochir Plast Surg 2011; 43 (4): 208- 214 (peniplastica totalis). Zentralbl Chir 1936: 63: 34. Ma S, Cheng K, Liu Y. Sensibility following 1271 innervated free radial forearm flap for penile 23. Gillies HD, Harrison RJ. Congenital absence of reconstruction. Plast Reconstr Surg 2010; 127 the penis with embryological consideration. Br J (1): 235- 241 Plast Urol 1948: 1: 8 35. Hoebeke PB, Decaesteker K, Beysens M, 24. Bettocchi C, Ralph DJ, Pryor JP. Pedicled pubic Opdenakker Y, Lumen N, Monstrey SM. Erectile phalloplasty in females with gender dysphoria. implants in female-to-male-transsexuals: our BJU Int 2004; 95: 120-124 experience in 129 patients. Eur Urol 2010; 57 (2): 25. Persky L, Resnick M, Desprez J. Penile 334-40 reconstructionwith gracilis pedicled grafts. J Urol 36. Ma S, Liu Y, Chang T, Cheng K. Long-term 1983: 129: 603-605 follow-up of sensation recovery of the penis 26. Chang TS, Hwang WY. Forearm flap in one-stage reconstructed by Cheng’s method. Plast Reconstr reconstruction of the penis. Plast Reconstr Surg Surg 2010; 127: 1546- 1552 1984; 74: 251–8 37. Rubino C, Figus A, Dessy LA. Alei G, Mazzocchi 27. Song R, Gao Y, Song Y, Yu Y, Song Y. The M et Al. Innervated island pedicled anterolateral forearm flap. Clin Plast Surg 1982; 9: 21–6 thigh flap for neo-phallic reconstruction in female- to-male transsexuals. J Urol 1993; 150 (40): 28. Gilbert DA, Schlossberg SM, Jordan GH. Ulnar 1093-8 forearm phallic reconstruction and penile 38. Papadopulos NA, Schaff J, Biemer E. The use of reconstruction. Microsurgery 1995: 16: 314-321 free prelaminated and sensate 29. Garaffa G, Christopher AN, Ralph DJ. Total osteofasciocutaneous fibular flap in phalloplasty. phallic reconstruction in female-to-male Int J Care Injured 2008; 39s: s62-s67 transsexuals. Eur Urol 2010; 57 (4): 715- 722 39. Felici N, Felici A. A new phalloplasty technique: 30. Garaffa G, Raheem AA, Christopher NA, Ralph the free anterolateral thigh flap phalloplasty. J DJ. Total phallic reconstruction after penile Plast Reconstr Aesthet Surg 2006; 59 (2): 153-7 amputation for carcinoma. BJU Int 2009; 104 (6): 40. Garaffa G, Raheem AA, Ralph DJ. An update on 852-6 penile reconstruction. Asian J Androl 2011; 13 (3): 31. Selvaggi G, Monstrey S, Hoebeke P, Ceulemans 391- 394 P, Van Landuyt K, Hamdi M, Cameron B, 41. Garaffa G, Sansalone S, Ralph DJ. Penile Blondeel P. Donor-site morbidity of the radial reconstruction. Asian J Androl 2012; Mar 19 (E forearm free flap after 125 phalloplasties in pub ahead of print) gender identity disorder. Plast Reconstr Surg 42. Garaffa G, Ralph DJ, Christopher N. Total 2006; 118 (5): 1171-7 urethral construction with the radial artery based 32. Lumen N, Monstrey S, Ceoulemans P, Van Laeke forearm free flap in the transsexual. BJU Int 2010; E, Hoebeke P. Reconstructive surgery for severe 106 (8): 1206- 1210 penile inadequacy: phalloplasty with a free radial forearm flap or a pedicled anterolateral thigh flap. Adv Urol 2008; Nov 4 (E pub ahead of print)

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REVIEW ARTICLES

Small Penis Syndrome: Fact or Fiction

Maher Zabaneh, MD

Senior Consultant Urology and Sexual Medicine, Amman, Jordan Treasurer of MESSM Most of the patients we deal with are physically normal Micropenis or Microphallus is a penis that is (2.5) but they frequently fall victims for “ enhance your penis standard deviations below the mean for the age and “ adds on internet, etc. , and they are hard to convince race of the child (1) .This definition translates to a and usually insist on unnecessary medical or surgical stretched penis length of less than 1.9 cm. long at interventions. This represents a big difficulty in our birth. Statistically occurs in 0.6 % of the population. In practice. extreme cases there is barely any shaft. Several abnormal conditions could be associated with For this reason, Hussein Ghanem, Sidney Glina, micropenis. Most of these conditions are of reduced Pierre Assalian and Jacques Buvat, collaborating with prenatal androgen production or effect, such as the ISSM Standards Committee, prepared a “position testicular dysgenesis, Klinefelter syndrome, leydig cell paper” on how to manage the complaint of a small hypoplasia, defects of testosterone synthesis, penis in normal men? androgen insensitivity, congenital hypogonadism. It The outline of this paper is as follows: also occurs in many genetic malformation conditions  What is the normal penile size? with no sex chromosome involvement. It is important  What do patients complaining of small penis to know, that most of the children under the age of 14 suffer from? years, who are referred for micropenis, do not have  Management, Education and Counseling. this condition. Usually they have a penis concealed in  Traction devices: Do they have a role? extra suprapubic fat, or a large body, and though the  Surgery: results and satisfaction. penis appears smaller than usual. And in some cases  Conclusions. delayed is the reason for the phenomenon. What is the normal penile size? But what is the situation in our region? Is it a Measurements were done by physicians and patients significant problem? as well (self- reporting). Studies relying on patient’s The largest series originating from the Middle East self- reporting showed larger penile sizes. were based on studies by Shamloul and Ghanem et al. The accumulated data on average penile size Shmaloul, in 2005, studied the cases of 92 patients measured by physicians were as follows: and found no abnormalities among them(2). In Ghanem’s study in 2007, only 4 out of 250 patients (2 %) had abnormal findings(3).

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 Shortening (penis entrapped in infrapubic scar). Erect length 12,9 cm.  Psychological complications. Stretched length 12,5 cm. Erect circumference 12,0 cm. What improvement is expected from surgery? Flaccid 8,0 cm. A (1-2 cm.) length gain is considered a success, but patients are informed that there is a possibility of no circumference (7) actual gain. Girth enhancement is more significant . Concerning patients satisfaction with surgery, Li et al. , What do patients complaining of small penis found that only 27 % of the patients were satisfied and actually suffer from? As mentioned before, Ghanem reported abnormalities they advised that surgery should be discouraged and dysmorphophobic patients should be referred for in 2% of his patients. Shamloul, Spyropoulosa and (8) Mondaini reported no abnormalities (3 ). This led us to psychiatric counseling . Generally , guidelines for the fact, that many men are simply misinformed or surgery proposed by Wessells and Lue et al. were : suffer from body dysmorphic disorder and therefore, Flaccid length less than ( 4 cm. ) rarely a true micropenis was diagnosed. Shamloul Stretched or erect length less than ( 7.5 reported that many of his patients believed that the cm. ) size of the flaccid penis was (14 cm). Mondaini et al. reported that penile length is normal in most men Is there a role for traction / stretching devices? seeking penile lengthening procedures(4). Alter (1998) and Ralph (2000 ) recommend the use of these devices in case of Peyronie’s disease Management postoperatively to decrease the chances of penile (9) Various surgical techniques have been described: entrapment into the scar . 1. Lengthening procedures:  Suspensory ligament manipulation. Does education, psychotherapy and counseling  Inverted (V-Y) skin incision. work? The answer seems to be a BIG YES, since, based on  Full thickness skin grafting. studies by Da Ros (1994), Shamloul (2005) and  Liposuction. Ghanem (2007), only 2 % of patients choosed surgery.  Correction of the cause (ventral chordee or Hussein Ghanem et al. published a paper entitled scrotal web). structured management and counseling for patients  Others (cartilage transplant). (3) with a complaint of a small penis . This paper is 2. Girth enhancement: considered a “ road map “ for dealing with the patients.  Lipoinjection. The main points of the paper discuss the followings:  Dermal fat graft (Alter, 1998).  Initial meeting.  Injection of synthetic materials.  Explaining the facts.  Saphenous vein graft.  Advise about the true options. Complications of penile augmentation surgery(5) (6)  Conclusion of the consultation.  General surgical risk : At the initial meeting, we should show empathy to the  Infection. patient. Say something like “I know that you have been  Bleeding. very concerned about the size of your penis for many  Death. years as many young men (i.e. he is not alone).Take  Lengthening procedures: him seriously: measure both flaccid and stretched  Scrotalization. penis and use PGE 1 injection if you feel that he is  Dog Ears. concerned in erect size. Measure his testes too. Then  Skin sloughing. explain the facts that the stretched length is (7-17 cm.  Girth augmentation: mean: 12 cm.) and the flaccid length is of no functional  Nodule formation due to uneven fat resorbtion significance (66 % of patients are mainly concerned in

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flaccid length (Mondaini et al. (4)). Let him know about Johns Hopkins medical journal, 1980; the wide elasticity of the vagina and that the is 146(4):156-163. at the entrance of the vagina. Then comes your advice 2- Shamloul R. Treatment of men complaining of about the true options: “Do not believe the adds on short penis Urology, 2005; 65:1183-5. found on the internet, etc.”, and “medical treatment 3- Ghanem H, Shamloul R, Khodeir F, ElShafie (testosterone) will not work except in cases of H, Kaddah A, Ismail I. Structured management hypogonadism with a true micropenis, if started at very and counseling for patients with a complaint of early age”. Inform him that dermal grafts would a small penis. J Sex Med 2007; 4: 1322– improve the girth, but he might not be happy with the 1327. final cosmetic appearance and will have a significant 4- Mondaini N, Ponchietti R, Gontero P, Muir GH, scar at the donor area, and the length enhancement Natali A, Caldarera E et al. Penile length is will not be more than (1-2 cm), if any (most patients normal in most men seeking penile comment that they expect a (5-7 cm. enhancement). lengthening procedures. Int J Impot Res At the end you conclude the consultation with showing 2002; 14: 283–286. empathy again by explaining that you understand that 5- Wessels H, Lue TF, McAninch JW: a problem that has been present for many years will Complications of penile lengthening and not disappear simply by your reassurance alone and augmentation seen at one referral center. J. advise for psychiatric consultation. Do not just “dump” Urology, 1996; 155; 5; 1617-20 him on the psychiatrist, but also mention that you are 6- Alter GJ: Reconstruction of deformities always there if he needs to return for more information. resulting from penile enlargement surgery. J. Also you might consider treatment with SSRI-s. Urology, 1997; 158(6):2153–2157 7- Spyropoulos E, Borousas D, Mavrikos S, Conclusions and recommendations revised by the Dellis A, Bourounis M, Athanasiadis S. Size of ISSM Standards Committee: external genital organs and somatometric  According to the available data, most of the parameters among physically normal men patients are either misinformed or suffer from a younger than 40 years old. Urology 2002; 60: psychological disorder. 485–489; discussion 490–481.  There is no effective and safe surgical 8- Li CY, Kayes O, Kell PD, Christopher N, intervention, medication or device .The penile Minhas S, Ralph DJ. Penile suspensory augmentation procedures are only experimental ligament division for penile augmentation: procedures. indications and results. Eur Urol 2006; 49:  A structured counseling and management 729–733 protocol is suggested. (Grade of 9- Alter, G.J. “Penile Enlargement Surgery,” recommendation: C) Techniques of Urology 4:2 (1998), p.10-76. 10- Ralph DJ et al.: The penile suspensory References: ligament , AUA 95 th. Annual meeting, 2000 1- Lee PA, Mazur T, Danish R et al. “Micropenis. I. Criteria, etiologies and classification “. The

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HAVE YOU READ THESE PAPERS? Traction therapy for men with shortened penis Shaeer's Glans Augmentation Technique: A Pilot prior to penile prosthesis implantation: A pilot Study study Shaeer, O. Levine, L.A. , Rybak, J. JSM 2012; 9(12):3264-69 JSM 2011; 8(7):2112-17 Introduction: Augmentation of the may be Introduction: Loss of penile length after penile indicated for cosmetic reasons, lack of glans prosthesis implantation is one of the most common tumescence following implantation of a penile complaints. There is no recognized reliable technique prosthesis, or asymmetry following girth augmentation to gain length once the device is placed. of the shaft. Many augmentation techniques have Aims: This non-controlled pilot study was designed to been offered to increase the length and girth of penile evaluate the efficacy and safety of external penile shaft, but not the glans penis, with the exception of traction therapy in men with a shortened penis used hyaluronic acid gel injection that is known to decrease before inflatable prosthesis implantation. Methods: Ten sensitivity of the glans and is restricted for cases with men with drug refractory erectile dysfunction and a premature ejaculation. complaint of a shorter penis as a result of radical Aim: This work is the first report on glans prostatectomy in four, prior prosthesis explantation in augmentation by grafting. Main Outcome Measures: four, and Peyronie's disease in two were entered into Maximum circumference of the glans, self-reported this trial. External penile traction was applied for 2- impression of the augmented volume and glans 4hours daily for 2-4months prior to prosthesis surgery. sensitivity. Methods: Ten males requesting Main Outcome Measures: Baseline stretched penile augmentation of the glans were selected for the study length (SPL) was compared with post-traction SPL and after failing counseling, with normal erectile function postimplant inflated erect length. A non-validated and ejaculatory control. Two ventral incisions were cut questionnaire assessed patient satisfaction. Results: along the ventral aspects of the coronal sulcus, one on All men completed the protocol. Daily average device either side of the frenulum. Lateral glans flaps were use was 2-4hours and for up to 4months. No man had dissected on either side. The urethra was measured or perceived length loss after inflatable circumvented, creating a plane all around it. A dermal penile prosthesis placement. Seventy percent had fat graft was inserted into the space created. The flaps measured erect length gain compared with baseline were closed by simple absorbable sutures. pre-traction SPL up to 1.5cm. There were no adverse Results: Maximum circumference of the glans events. increased by 16.6%, declining to 14.2% by the last Conclusion: External traction therapy appears to result follow-up visit (10-12 months), a 2.3% decline. Self- in a preservation of penile length, as no man had reported impression of the augmented volume was measured or perceived length loss following prosthesis high and well maintained over the follow-up period. placement, but in fact, a small length gain was noted in Glans sensation, engorgement, erectile function, and 70% of the subjects with no adverse events. The ejaculatory control were preserved. Conclusion: This protocol is tedious and requires compliance to be pilot study on glans augmentation by grafting reports effective. External traction therapy prior to inflatable promising results with retention of the added volume at penile prosthesis placement appears to preserve and 1-year follow-up, preservation sensitivity and possibly result in increased post-prosthesis implant engorgement, and no adverse effects on erectile erect length. function or ejaculatory control.

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Tadalafil Enhances the Inhibitory Effects of additional inhibition of contractions. Conclusions. Tamsulosin on Neurogenic Contractions of Human While tadalafil enhances cGMP accumulation and and Bladder Neck potentiates prostate relaxation, tadalafil combined with Angulo, J., Cuevas, P., Fernández, A., La Fuente, tamsulosin results in enhanced inhibition of neurogenic J.M., Allona, A., Moncada, I., Sáenz de Tejada, I. contractions of HPP and HBN. JSM 2012; 9(9):2293-06

Introduction: Lower urinary tract symptoms secondary Does Current Scientific and Clinical Evidence to benign prostatic hyperplasia (BPH-LUTSs) may be Support the Use of Phosphodiesterase Type 5 associated with erectile dysfunction (ED). Inhibitors for the Treatment of Premature Phosphodiesterase type 5 (PDE5) inhibitors used for Ejaculation? A Systematic Review and Meta- treating ED have shown clinical benefit in patients with analysis LUTS but their actions in human LUT tissues are not Asimakopoulos, A.D., Miano, R., Agrò, well defined. E.F., Vespasiani, G., Spera, E. Aim: To determine the effects of the long-acting PDE5 JSM 2012; 9(9):2404-16 inhibitor, tadalafil, on smooth muscle tone in human prostate and bladder neck as well as to evaluate the Introduction: Premature ejaculation (PE) is a highly influence of tadalafil on the efficacy of the α-adrenergic prevalent and complex syndrome that remains poorly receptor antagonist, tamsulosin, in inhibiting contractile defined and inadequately characterized. responses in these tissues. Pharmacotherapy represents the current basis of Methods: Strips of human peripheral prostate (HPP), lifelong PE treatment. human internal prostate (HIP), and human bladder Aim: The goal of this study was to assess the role of neck (HBN) were obtained from organ donors and phosphodiesterase type 5 inhibitors (PDE5-Is) in the patients with BPH. The strips were then disposed in treatment of patients with PE without associated organ baths to evaluate nitric oxide/cyclic guanosine erectile dysfunction (ED). monophosphate (cGMP)-mediated relaxation and Main Outcome Measure: The post-treatment cGMP kinetics in HPP and HIP, and electrical field intravaginal ejaculatory latency time was used as the stimulation (EFS)-induced neurogenic contractions in primary end point of efficacy. HPP and HBN. Methods: A systematic review of the literature was Main Outcome Measures: Tadalafil-induced effects on performed by electronically searching the MedLine sodium nitroprusside (SNP)-induced relaxation and database for peer-reviewed articles regarding the cGMP accumulation in HPP and HIP and influence of mechanism of action and the clinical trials of PDE5 in tadalafil and tamsulosin on EFS-induced contractions the management of PE. A meta-analysis of these of HPP and HBN. clinical studies was performed to pool the efficacy. Results: SNP-induced relaxation of HPP and HIP was Results: Twenty-nine articles that examined the significantly potentiated by tadalafil (30-60nM). SNP- supposed mechanisms of action and 14 articles that induced cGMP accumulation in HPP and HIP was reported data from clinical studies were reviewed. The enhanced by tadalafil (30-60nM), but significant PDE5 may exert their influence by increasing the difference was only obtained in HPP. EFS-induced levels of nitric oxide both centrally (reducing contractions sensitive to tetrodotoxin in HPP were sympathetic drive) and peripherally (leading to significantly inhibited by tadalafil (30nM) but not by smooth-muscle dilatation of the seminal tract). These tamsulosin (0.01-100nM) or vehicle. Further inhibition drugs may also induce peripheral analgesia to prolong of neurogenic responses in HPP was achieved by the duration of the , increase confidence, combining tadalafil and tamsulosin treatments. improve the perception of ejaculatory control and Tamsulosin, but not tadalafil, significantly reduced overall sexual satisfaction, and decrease the EFS-induced contractions in HBN, but the postorgasmic refractory time for achieving a second coadministration of both therapies resulted in erection after ejaculation.

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Concerning the efficacy, the meta-analysis shows an characterized by the lack of a unique PE definition, overall positive effect for the use of PDE5 as and the lack of appropriate endpoints for outcome monotherapy or as components of a combination evaluation of a placebo control arm and of Institutional regimen in the treatment of PE. The major limitations Review Board approval. Conclusion. There is of the published literature included poor study design, inadequate, partial basic, and clinical evidence to the absence of solid methodology, which was support the use of PDE5 for the treatment of PE.

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HAVE YOU READ THESE PAPERS? The following papers are selected from "The 16th Congress of European Society for Sexual Medicine" that was held in Amsterdam December 2012.

THE ERECTILE DYSFUNCTION AND STATINS FAT BOOSTS, WHILE ANDROGEN RECEPTOR (EDS) TRIAL ACTIVATION COUNTERACTS, BENIGN Kirby, M.; Trivedi, D.; Welsted, D. PROSTATIC HYPERPLASIA- ASSOCIATED PROSTATE INFLAMMATION This study was completed with 113 men with an Vignozzi; Gacci; Cellai; Santi; Corona; Morelli; average age of the patients was 56.1 years, BMI 27.7. Rastrelli; Comeglio; De Nunzio; Carini; Maggi They were randomised to receive either 40 mg simvastatin or a placebo for six months. An This study was aimed at evaluating whether improvement in IIEF was more noted in Patients with Metabolic syndrome MetS was associated with benign Severe ED at baseline than patients with prostate hyperplasia BPH-related inflammation by Mild/Moderate ED . There was an Increase in reported investigating the in vitro effect of oxidized low- density Satisfaction over time with Mild/Moderate ED reporting lipoprotein (oxLDL) the most relevant autoantigen greater Satisfaction than those with Severe ED. Both described in dyslipidaemia–on human prostate stromal 10 year CVD risk and LDL were reduced by Statin cells. treatment. The study found that not only fats could have a The study concluded that Simvastatin improved the detrimental effect on prostate health, boosting prostate sexual health related quality of life of these men and inflammation, but also that DHT had beneficial effects that this approach has a >80% probability of being cost in counteracting lipid and insulin-induced prostatic effective. alterations, suggesting that androgens may have unexpected beneficial effects on prostate health. USAGE OF ANGIOTENSIN CONVERTING ENZYME INHIBITOR LISINOPRIL IN THE TESTOSTERONE AND / TREATMENT OF HYPERTENSIVE PATIENTS WITH RISING PSA: IS THE LINK GETTING WEAKER AND ERECTILE DYSFUNCTION THE PICTURE CLEARER? Gorpynchenko; Romaniuk; Gurzhenko; Kornienko; Chitale; Banerjee; Hull; Rooney Gurzhenko This study aimed at investigating the presumed The study included 108 patients with stage II arterial association between TRT and initiation of prostate hypertension , aged 45–68 years. After 3 weeks of cancer or a rise in PSA. 100 men with male sexual Lisinopril the blood pressure returned to normal in 97 disorder MSD / lower urinary tract symptoms LUTS patients (89.8%). The daily dose was 10 mg in 66 were prospectively recruited with an initial work-up patients, 20 mg–in 31. including QoL questionnaire, testosterone and PSA Indicator “erectile function” of IIEF has increased from assay at baseline and at 4–6 monthly follow-up. 10,44 ± 0,57 to 16,27 ± 0,42 (p < 0,01), «satisfaction Patients with rising PSA were offered prostate scan with sexual intercourse” from 6,98 ± 0,25 to 10,55 ± and biopsies whilst their TRT was put on hold. Of the 0,44 (p < 0,05), “orgasm”–from 5,21 ± 0,32 to 6,11 ± 20 patients on TRT for MSD with a mean follow-up of 0,37 (p < 0,05), “overall satisfaction”–from 4,02 ± 0,27 18 months, 16 showed a therapeutic benefit with to 6,33 ± 0,36 (p < 0,01), “libido” from 7,12 ± 0,39 to significant rise in their testosterone without a 11,74 ± 0,87 (p < 0,01). concomitant rise in their PSA. 3/20 had a rise in PSA The study concluded that ACE inh Lisinopril produced but negative biopsies for prostate cancer and 1/20 excellent results in 43.6% of cases studied, good in patients with normal PSA but an abnormal DRE also 19.4%, satisfactory in 29.6% and unsatisfactory in had negative biopsies. 7.4%.

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The study concluded that Men with MSD on TRT did IMPAIRED MASTURBATION INDUCED not show any rise in PSA in the majority and those : A NEW CARDIOVASCULAR RISK with a minimal rise in PSA show no evidence of FACTOR FOR MALE SUBJECTS WITH SEXUAL prostate cancer. Larger longitudinal studies with longer DYSFUNCTION follow-up are needed to convince clinicians that with Rastrelli; Boddi; Corona; Mannucci; Maggi close monitoring it is not unsafe to offer TRT for men with MSD. A series of 4,031 male patients attending the Outpatient Clinic for sexual dysfunction was HIGH AORTIC/PENILE INDEX (API) IS A MARKER retrospectively studied. Among these subjects, 862 OF CORONARY ARTERY DISEASE patients (64%) reported autoeroticism during the last IN ASYMPTOMATIC MIDDLE-AGED three months and only this subset was considered in HYPERTENSIVE PATIENTS WITH ERECTILE the following analyses. Several clinical, biochemical DYSFUNCTION and instrumental (PGE1 test and penile color Doppler Vlachopoulos; Ioakeimidis; Rokkas; Aggelis; Terentes- ultrasound) parameters were studied Printzios; Aggelakas; Synodinos; Pietri; Subjects with an impaired erection during Askitis; Stefanadis masturbation (46% of those reporting autoeroticism) had more often a positive personal or family history of In this study 155 asymptomatic non-diabetic treated CVD, a higher risk of reduced intercourse and sleep- hypertensive men (40–60 y/o) with ED were evaluated related erections, hypoactive sexual desire and using exercise treadmill test and stress perceived reduced ejaculate volume, and impaired echocardiography. Men with positive one or both of the PGE1 test response. Prolactin levels were lower in two non-invasive tests were referred for coronary those having impaired erection during masturbation. angiography in order to document coronary artery In the longitudinal study, unadjusted incidence of disease CAD. All patients underwent penile Doppler major adverse cardiovascular events MACE was ultrasonography evaluation of penile peak systolic significantly associated with impaired masturbation velocity (PSV) in addition to carotid–femoral pulse induced erections. When dividing the population wave velocity (PWV). Aortic/penile index (API) was according to the median age and diagnosis of developed to describe the severity of extracoronary diabetes, the association between impaired vascular dysfunction with the formula: API = PWV/ masturbation-induced erections and incidence of PSV. MACE was maintained only in the youngest (<55 year- Coronary angiography revealed coronary stenotic old) and in non-diabetic subjects, even after adjusting lesions in 19 men with non-invasive evidence for for confounders. ischemia (12%). The prevalence of Grade II/III This study indicates that masturbation-induced hypertension was not different between CAD patients erections, can provide further insights on forthcoming and subjects without CAD. CAD patients compared to MACE in particular in “low risk” subjects. subjects without CAD had higher PWV (9.3 vs 8.6 m/s, P < 0.01), lower PSV (23 vs 30 cm/s, P < 0.01) and a ONE PATIENT OUT OF FOUR WITH NEWLY higher API. DIAGNOSED ERECTILE DYSFUNCTION IS A The study showed that API allows an accurate YOUNG MEN interpretation for the interrelationships between Salonia; Capogrosso; Colicchia; Ventimiglia; hypertension, ED and CAD and predicts CAD with Suardi; Ferrari; Clementi; Castagna; Rigatti; high values of both sensitivity and specificity, allowing Montorsi the identification of hypertensive men who might warrant more intensive follow-up. This study analyzed complete data from 790 patients seeking first medical help for new-onset sexual dysfunction. All patients completed the International Index of Erectile Function (IIEF) domains. It was

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found that new-onset ED as the primary disorder was THE “KIEL KNOTS” TECHNIQUE FOR found in 439 (55.6%) men; of them, 26% were ≤40 TREATMENT OF CONGENITAL AND ACQUIRED years of age [mean (median) age: 32.4 (33.0); range: PENILE DEVIATION 17–40 years]. Young ED men had a lower mean BMI Osmonov; Jünemann and a higher circulating total testosterone as compared with patients >40 years, but a lower rate of A novel addition on the surgical correction of the penile stable sexual relationship, a more frequent smoking of curvature based on the 16-dot plication was cigarettes and use of drugs (ie, marijuana, cocaine propposed by this study in Kiel University. The and heroin) than older patients. technique proposed burying the knots in a shallow This analysis concluded that one in four patients with trough of incised tunica. new-onset ED was younger than 40 years, with The study was performed on 20 patients with a penile comparable rates of severe ED with older patients. deviation, average age 36.8 years (24–52) with a Follow-up time of 26 months. In 8 patients the AGING MALE SYMPTOMS SCALE AS A WAY TO deviation was congenital, in 12 patients it was an DETECT HYPOGONADISM IN YOUNG MEN acquired deviation. The deviation was >30° in all Bogolyubov, Artamonov, Pokrovskaja, Dmitriev patients. Instead of plicating with one suture for 4 dots, the modification uses one suture for two dots with the In a study on 216 men aged 17–23 years a survey was knot buried in a shallow trough created by a scalpel. carried out on a scale of Aging Males Symptoms There were no problems with erectile function. In a (AMS). Examination, calculation of body mass index, follow-up of 2 years, 90% of the patients remained blood test for testosterone and sex binding without recurrence of deviation. None of patients globulin, the calculation of the free and bioavailable reported problems with the suture knots. fraction of testosterone were undergone. Symptoms of androgen deficiency of various degrees HOW MANY DOTS IN THE 16 DOT TECHNIQUE? were found in 27.3%. During the inspection of young Zaazaa, A.; Abdelal, A.; Selim, O; Ghanem, H men with symptomatic androgen deficiency (n = 59), scrotal pathology was detected in 21 persons (35.6%), In this study from Egypt, 19 patients with congenital and in 11 men (18.6%) left varicocele grade 2–3. curvature of the penis underwent correction of their Sixteen men with symptomatic androgen deficiency curvature using the 16 dot technique described by lue performed blood sampling to determine the level of et.al. Curvatures ranged from purely ventral, to ventral testosterone. In assessing the androgenic hormonal with lateral deviation, to curvature associated with axis status was revealed that 6 (37.5%) had low total rotation of the penis. testosterone (<12 nmol/L). Calculation of free and The number of dots used in the operation varied from bioavailable testosterone showed that 2 (12.5%) 16 to up to 40 dots. All patients had successful surveyed men had decreased free testosterone and 11 correction of their curvature. 16 dots were used in 10 (68.8%) had a low bioavailable testosterone. patients (43.48%), less than 16 dots were used in 4 Therefore, the symptoms of androgen deficiency in patients (17.39%) and more than 16 dots were used in combination with low testosterone (including total, free 9 patients (39.13%). This study concluded that the and bioavailable) were detected in 14 (87.5%) of number of dots used positively correlated with the young men. Men who had low testosterone were degree of ventral curvature, and that it was safe to overweight in 14.3% of cases . increase the number of dots to allow for efficient This study concluded that the Aging Males Symptoms correction of the curvature. scale can be used to screen for androgen deficiency in young men in the initial stages of diagnosis.

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SIGNIFICANT NOCTURIA IS ASSOCIATED WITH school age with episodes varying from 2–3 times per TESTOSTERONE DEFICIENCY, week for at least 1–2 years. The first sexual INDEPENDENT OF AGE AND PROSTATE SIZE intercourse and the appearance of PE occurring Yang, D.; Kim, J. Lee, S. W. Moon, D. between 17 and 25 years of age. Patients were asked to answer the following: DSI-R This Korean study examined 545 patients with a mean “Differentiation of Self Inventory”, SRO “Sex-Role age of 58.48 ± 12.58 years, complaining of mean Orientation Scale”, IMS “Index of Marital Satisfaction”, nocturia of 2.12 ± 1.17 per night. Mean testosterone ISS “Index of Sexual Satisfaction”, HAM-D “The levels were 4.92 ± 2.02 ng/dL. Multivariate linear Hamilton Depression Evaluetion Scale”, AMS “The regression models showed serum testosterone levels Aging Male’s Symptoms Scale”. were significantly affected by age, BMI, as well as The data revealed that 47% of subjects had difficulty nocturnal polyuria index but not nocturnal bladder sleeping, suffered from irritability and excessive capacity index. Logistic regression showed perspiration combined with a general decline in testosterone deficiency showed significant risk physical ability and beard growth. 63% showed a associated with nocturnal polyuria but not other factors decrease in spontaneous morning erections. An associated with nocturia. excessive dependence on the partner was exhibited The study concluded that nocturia was associated with by 32% while 21% earned less than the partner. 19% decreased serum testosterone, independent of age found sex a chore, 15% experienced difficulty making and prostate volume. decisions in the absence of the partner, 37% were unable to feel pleasing for the partner while, 12% were PREMATURE EJACULATION (PE) AND INFANTILE inclined to do everything in a rush and 9% found it NOCTURNAL ENURESIS difficult to accept pleasure. Longhi, Franceschelli, Colombo, Salonia. The study seems to show that PE, in particularly emotional and insecure subjects, substitutes, in An Italian study examining the correlation between age, infantile nocturnal enuresis. It demonstrates the Premature Ejaculation and Infantile Nocturnal Enuresis difficulty the subject has in “controlling emotions and in 75 subjects, affected by non physiological PE from dealing with the beat of the female world.” the first instance of sexual intercourse.Patients had an average age of 38 with a partner of at least one year’s standing and had complained of secondary enuresis at

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CASE REPORTS IN SEXUAL MEDICINE Male after Transpelvic Gunshot Wound Further hormonal and genetic evaluations were Injury performed to investigate the etiology of what seemed Rafael Boscolo-Berto, Guido Viel, Daniela I. to be a congenital (and not post-traumatic) Raduazzo, Giovanni Cecchetto, and Walter malformation, especially focusing on cystic fibrosis Artibani (CF), a disease often presenting with bilateral absence Urol. J. 2012; Vol. 9 Iss. 4:714-717 of the vas deferens. Luteinizing hormone, follicle stimulating hormone, prolactin, 17-s-estradiol, and A 35 year-old Caucasian male presented with testosterone were normal. Screening for CF infertility. His past medical and surgical history showed transmembrane conductance regulator (CFTR) gene only an old trans-pelvic gunshot wound injury due to a mutations revealed heterozygosis for delta F508 high-power military weapon during the Balkan conflict. mutation on a background of a poly-T genotype of Subsequently, an emergency exploration laparotomy 7T/9T. Therefore, the diagnosis was found to be was performed on the battlefield, but no further congenital bilateral absence of the vas deferens technical details were available. Physical examination, (CBAVD) associated with CFTR mutation and poly-T revealed surgical scars on the anterior abdominal wall genotype of 7T/9T. on an umbilical-pubic and a right inguino-crural route. As a result, surgical reconstruction of the spermatic The entrance wound was detected on the lateral route to regain a natural was excluded. surface of the upper right thigh at the highness of the Nevertheless, pregnancy could be obtained using the trochanteric region, while the exit wound was intracytoplasmic injection; hence, recognized a little bit higher on the lateral surface of endocrinologic and genetic counseling was provided. the upper left thigh. The external genitalia were normal In a man with CBAVD, it is important to examine the and vas deferens was bilaterally palpable. Semen couple for CF mutations, determining both the analysis showed a normal pH of (7.5) and the volume genotypes and the consequent risk to transmit CF by of (3.0 mL). On scrotal ultrasonography, the assisted reproduction. There is a 25% chance of , vas deferens, and testicular parenchyma having a baby with CF if the man is heterozygous and appeared normal. Fine-needle biopsy showed normal a 50% if the man is homozygous when the female bilaterally. The final diagnosis was partner is found to be a carrier of CFTR. Even in the obstructive . Treatment options were case of negative female partner for known mutations, discussed with the patient and a vas deferens her chance of carrying an unknown mutation is about recanalization by bilateral vaso-vasostomy was 0.4%. suggested. For the evaluation of the possible outcome of such a Perineal Ectopic Testis surgical reconstruction, a retrograde and micturitional Gokhan Koc, Selim Yavuz Sural, Devrim Nihat Filiz, urethrocystography was performed which Yuksel Yilmaz demonstrated a regular morphology of the urethral Urol J. 2012; Vol. 9, No. 1:433-435 segments with an adequate vesical neck opening in the absence of deforming outcomes due to previous A 19-year-old male presented with a perineal mass surgery. To establish the vas deferens length into the and discomfort. Examination showed an empty and pelvis, a simultaneous transperineal ultrasoundguided poorly developed left hemi-. vesiculography was performed demonstrating the The contralateral testis was in its normal location in the bilateral presence of normal , and an right hemi-scrotum. An oval-shaped soft mass was antegrade scrotal vasography was also performed detected in the perineum measuring 4×5 ×6 cm. A which surprisingly revealed that the vas deferens clinical diagnosis of perineal ectopic testis was made. truncated at the upper level of the scrotum, without a Because of the patient’s age, orchidectomy was pathogenetic correlation with the patient’s past clinical recommended for the left perineal testis. However, the history. patient wanted his testis placed in the scrotum;

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therefore, a left orchiopexy was done. Surgical or any other skin lesion). The glans appeared entirely exploration was performed through inguinal skin normal, with no features to suggest carcinoma in situ. crease incisions, then the gubernaculum was fixed to However, there was an evidence of mild, painless the perineum. Using the dartos pouch technique, the chronic on the ventral aspect along the testis was fixed in the left side of the scrotum. coronal sulcus, but not covering any aspect of the Postoperative examination at one month demonstrated glans penis. Groin lymph nodes were normal. On a normally located left testis in the scrotum. The digital rectal examination, benign enlargement of his patient was satisfied with the outcome of the surgery. prostate was noted. Perineal ectopic testis is a rare condition. The ectopic Past history included hypertension, hypothyroidism, location of the testis is associated with a number of chronic renal disease, abdominal aortic aneurysm, a complications, such as trauma, torsion, and infertility in posterior circulation stroke in 2005, in addition to bilateral cases. Therefore, treatment is mandatory. stable lower urinary tract symptoms. The patient had Most authors recommend surgical correction at erectile dysfunction for a long time and was approximately the age of 1 year, because definite consequently unable to comment upon (and seemed histological changes can be demonstrated in the unconcerned about) any penile curvature or deformity undescended testes. Orchiopexy is the treatment of on erection. The clinical diagnosis was Peyronie’s choice under the age of 2 years. If an atrophic testis is plaque/disease. Upon patient's request, bearing in detected, orchidectomy should be performed. If the mind the patient’s age, lack of symptoms; non-surgical testis cannot be palpated in the usual position, all the (conservative) management was agreed upon, and no possible sites for an ectopic testis should be carefully further invasive investigations or procedures were examined. It is advised that in cases of perineal planned or undertaken. No medical or drug therapy ectopic testis, surgery should be performed before 6 was offered for the penile plaque as the patient had no months of age even if not associated with inguinal bothersome symptoms related to it. hernia. incidence is increased in an Eighteen months later, the patient represented with ectopic testis than in a normal one. That's why, long- macroscopic haematuria and co-existent pneumonia. term follow-up was advised for this patient. Genital examination showed the pre-existent hard lump on the penile shaft with persistent paraphimosis Primary Penile Cancer + Peyronie’s Disease = and, on this occasion, a suspicious, erythematous, flat Diagnostic Difficulty: A Case of Delayed Diagnosis lesion on the glans penis was seen. Ultrasound with a Review of the Problem of Penile Neoplasms imaging of the urinary tract was unremarkable and Masquerading as, or Being Masked by, Peyronie’s flexible cystourethroscopy revealed induration and Disease erythema of the distal/anterior urethra but no urothelial Chris Hurrell, Stuart Irving, Melanie Shaw, Richard lesion in the urethra or bladder. Y. Ball and Sudhanshu Chitale However, the magnetic resonance imaging scan, The Open Urol & Nephrology J., 2012; 5: 24-27 showed abnormal texture in the entire penis, implying diffuse corporal infiltration throughout the organ. An 86 year-old male presented with a flat, disc-like, Multiple pelvic lymph nodes were involved (including painless plaque in the subcutaneous plane along the the left obturator, left iliac, and bilateral inguinal penile shaft and inseparable from the tunica albuginea. groups), bone metastases (rT4, N2, M1) was also The patient said that it had been unchanged for seen. The inferior left pubic ramus and the anterior several years. On physical examination, the plaque aspect of the inferior right pubic ramus were replaced was situated on the dorsal aspect of the mid-shaft of by an abnormal soft tissue. Metastatic deposits were the penis, and the inter-corporal septum was also seen also in both the right and left acetabula, with involved. The lump (5 cm long x 2 cm wide) was hard, possible early protrusio acetabulae on the right. The irregular, and non-tender. penis was the primary site of the tumor, and there was The penile skin was normal (i.e., there was no no clinical or radiological evidence that it was ulceration, excoriation, bleeding, discharge, phimosis metastatic from a different site.

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Three incisional wedge biopsies of the penile lesion midline of the abdomen, far from the scrotum and the were examined. They were taken from the shaft, groin. No history of inguinal herniorrhaphy or corpora and glans. Invasive squamous cell carcinoma vasectomy was reported. A histopathological section (up to grade 3) of the penis was seen in all the of a right testicular biopsy revealed normal sections with widespread necrosis as well as vascular spermatogenesis. The patient was diagnosed with and perineural permeation. The section from the glans obstructive azoospermia. Afterwards, reconstructions penis included some normal epidermis and also areas of both seminal tracts were performed upon the of squamous cell carcinoma in situ, confirming that the couple's request, because they strongly wanted to penis was the primary site of carcinoma. pursue the possibility of a natural pregnancy. Intra- Palliative/supportive care was offered in view of the operative vasography revealed that both vasa extent of the disease at diagnosis and the overall poor deferentia were interrupted at the internal inguinal prognosis. The patient died in hospital two months rings. The abdominal end of the left vas deferens later of a combination of heart failure, renal failure, and could not be identified, but the abdominal end of the pneumonia. The patient’s relatives did not consent to right spermatic duct was found in the abdominal cavity. clinical autopsy. The discharge from the stump of the testicular end of This case highlights a rare presentation of a squamous the vas deferens had no , whereas the right cell carcinoma of the penis in a man who seemed to epididymal tubules were dilated with motile have had Peyronie’s disease for several years. spermatozoa. Therefore, a right-sided vaso-vasostomy Moreover, this case suggests that urologists should and ipsilateral epididymovasostomy were performed have a high index of suspicion and low threshold for simultaneously. Disappointingly, post-operative semen investigating painless penile plaques/lumps that analyses showed that the patient still has simulate Peyronie’s disease, particularly in the elderly. azoospermia. Finally, he fathered a child by intracytoplasmic sperm injection (ICSI) using testicular Obstructive azoospermia as an unusual sperm that had been retrieved and cryopreserved at complication associated with herniorrhaphy of an the time of the testicular biopsy. omphalocele: a case report The case of this patient indicated that herniorrhaphy of Kazunari Tsuchihashi, Kazutoshi Okubo, Kentaro an omphalocele can be considered as an iatrogenic Ichioka, Takeshi Soda, Koji Yoshimura, Akihiro cause of obstructive azoospermia. This was the first Kanematsu, Osamu Ogawa and Hiroyuki report describing obstructive azoospermia as an Nishiyama unusual complication of this surgery. It is highly J. of Medical Case Reports 2011; 5:234 advised to pay attention to the seminal tracts in herniorrhaphy of an omphalocele, as well as in A 30-year-old Japanese male presented with 1 year of inguinal herniorrhaphy. infertility after his marriage. He had undergone herniorrhaphy for an omphalocele immediately after Priapism induced with single oral dose of birth. Multiple semen analyses revealed azoospermia, sildenafil: A rare case report but a scrotal examination showed no abnormalities in H. K. AGGRAWAL, DEEPAK K JAIN, RAJ YADAV the testes or in the vas deferens or epididymis Int J Pharm Pharm Sci, 2011; Vol. 3, Iss. 2: 9495 bilaterally. Magnetic resonance imaging of the scrotum revealed no abnormal findings in the seminal vesicles, A 25 year-old married healthy male presented to the the prostate or the ejaculatory ducts. An emergency department with a history of priapism of 72 endocrinological examination demonstrated that his hour- duration. He stated that he consumed a serum follicle-stimulating hormone, luteinizing non‐prescribed single tablet of sildenafil (50 mg) hormone and testosterone levels were within the purchased over the counter along with 250 ml of normal range (4.1 mIU/ml, 3.6 mIU/ml and 7.48 ng/ml, alcohol. Thirty minutes after drug intake, he respectively). On physical examination, the surgical developed painful priapism when he was viewing scar from his omphalocele repair was found in the pornographic material for sexual stimulation. The

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patient reported no history of intake of any priapism bilateral corporotomies were done with corporeal inducing drugs such as antihypertensives or dilation followed by placement of 9.5 mm diameter, 18 antipsychotics or any other drugs that may affect the cm long Genesis devices (Mentor Corp; Santa metabolism of sildenafil. No history suggestive of Barbara, CA, USA). This resulted in complete sickle cell trait, leukemia or multiple myeloma was correction. Closure of the wound was done with a reported. drain inside. The patient was followed for 6 months. Haemogram, coagulation parameters and serum He had an uneventful postoperative period and was chemistry were all within normal limits. Work up for doing well. sickle cell trait was negative. This case report presents a challenging case, where On physical examination, the corpus cavernosa was torsion was accompanied by severe ED. Penile de- rigid and the corpus spongiosum and glans were soft. gloving alone did not completely solve the problem. Patient was not welling to undergo any surgical However, with the implantation of the penile prosthesis intervention and insisted on oral medication. Priapism there was complete correction of the torsion. This wasn't relieved after aspiration and corporal wash technique is new and has not been previously followed by a winter procedure. Fifteen milliliters of reported. Its application is limited to special cases, but dark blood was aspirated using a 16 G needle. the results appear to be promising. Consent was taken for proximal caverno‐spongiosal It was concluded that the combination of penile de- shunting but patient refused for any surgical gloving and penile prosthesis implantation can intervention and left the hospital against medical successfully correct penile torsion accompanied by advice. Further follow up could not be done. ED even in severe cases, provided that the patient is a This case highlights the urgent need for steps to candidate for prosthesis implantation. prevent unauthorized prescription and misuse of sildenafil. It should only be used under professional Novel Extraction Technique to Remove a Penile guidance because abuse of such drug may lead to Constriction Device severe morbidity. Unfortunately, only few case reports Darren J. Katz, MD, Warren Chin, MD, Sree Appu, highlighted this side effect of sildenafil; therefore, it is MD, Matthew Harper, MD, Filip Vukasin, MD, Yeng difficult to draw concrete conclusion. More research Kwang Tay, MD, Chia Pang, MD, and Caroline directed towards the etiopathogenesis of this side Dowling, MD effect of sildenafil is needed. J Sex Med 2012;9:937–940

Correction of a 180 Degree (Upside Down) Penile This group from Melbourne presents one case of Torsion in a 55-Year-Old Patient with Severe removal of a reinforced cast iron locking nut of a Erectile Dysfunction vehicle towbar that had been lodged at the base of a Mohamed A Ismail, Mohamed Amin patient’s penis. The patient is 63 year old farmer with a UroToday Int. J. 2010 Dec.; Vol. 3, Iss. 6 15 year history of Parkinsonism and receiving pramipexaole a known drug to cause hypersexuality. A 55-year-old male presented with a long history of The patient presented to the emergency department erectile dysfunction (ED). The patient had uncontrolled having a cast iron locking nut from a vehicle towbar diabetes mellitus for 15 years, and he was a cigarette lodged at the base of his penis for about 24 hours. On smoker for 30 years. The patient was diagnosed with examination, he was distressed, had choreiform type severe arteriogenic ED with counterclockwise 180° movements, and was in . The penis (half circle) congenital penile torsion, and thus, he was was engorged, edematous, and progressively scheduled for surgery. becoming more swollen. Emergency department A decision was made to do a incision with physicians failed to remove the object due to extensive de-gloving of the penis during surgery. All skin and distal penile oedema and mechanical cutting of the subcutaneous adhesions were taken down, and this object was not applicable. resulted in partial correction of the torsion. Afterwards,

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Middle East Society for Sexual Medicine March 2013 – Issue 4

This technique of pseudo-pulley system included, 4-cm tender, fixed to underlying tissues, with mobile progressive distal-to-proximal tourniquet to the penis, overlying skin. No urethral discharge was observed. aspiration of the edema, passage of evenly spaced Penile sonography revealed a transonic, relatively wires under the ring, and sequential pulling on the homogenous, well-delineated lesion, 30 mL in volume, wires at a 45° angle. outside the spongiosum and corpora cavernosa, on the left ventrolateral side of the penis. Cultures of Penile Abscess and Urethrocutaneous Fistula purulent material obtained by puncture of the lump Following Intracavernous Injection: A Case Report revealed Klebsiella. Other causes of penile swelling Viorel Jinga, MD, PhD and Virgil Iconaru, MD, PhD were excluded. Department of Urology, “Prof. Dr. Th. Burghele” Under spinal anesthesia, subcoronal degloving Hospital, Bucharest, Romania incision was done exposing a well demarcated J Sex Med 2012;9:3270–3273 abscess under the Bukc’s fascia. The abscess was incised, pus was drained, and irrigation with saline and This team from Romania presents a rare case of 1:10 dilution of povidone-iodine was performed. Using penile abscess presenting 6 months after sharp and blunt dissection, the covering sheath of the intracavernous papaverine injection. A 49 year old abcess was excised down to the intact cavernosal man with a 2 years history of erectile dysfunction, tunica albuginea. already trained on intracavernous injection complained On postoperative day 12, an urethrocutaneous fistula from a penile swelling after 2 weeks from the last developed, 6 mm in diameter, on the ventral side of injection. The patient didn’t seek advice except after 6 the spongy urethra. The patient was initially managed months from onset of the swelling as the symptoms by suprapubic cystostomy; after 3 months, an Orandi were not severe. On examination the swelling was 6 x Urethroplasty was performed.

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NEWSLETTER

Middle East Society for Sexual Medicine March 2013 – Issue 4

EDUCATIONAL CALENDAR 2013 First global conference on contraception, 17th Pan Arab Conference on Diabetes PACD 17 reproductive and sexual health March 26 - 29, Cairo, Egyot 22 - 25 May, Copenhagen, Denmark Pure Spot Congress & Event Organizers European Society of Contraception and Reproductive 1 Awal Mayo Buildings, El Nasr Road Health Nasr City, Cairo Opalfeneweg 3 Egypt 1740 Ternat Tel. +20 2 267 21 944 Belgium Fax. +20 2 267 18 421 Tel. +32 2 582 08 52 Mail. [email protected] Fax. +32 2 582 55 15 Web. www.arab-diabetes.com Mail. [email protected] Web. www.escrh.eu/events/esc-events/2013 Meeting of the South Asian Society for Sexual Medicine (SASSM) 14th Biennial Meeting Of The Asia-Pacific Society March 29-31, 2013, Bangalore, India For Sexual Medicine (APSSM) Anil Kumar, Director May 31 - June 3, Kanazawa, Japan Astreix Department of Integrative Cancer Therapy and # 204 -B, A Block, Urology, No.3, Queens Corner Apts, Kanazawa University Graduate School of Medical Queens Road, Sciences, Bangalore - 560001. 13-1 Takara-machi, Kanazawa,920-8640 Karnataka State, India. Japan Tele : 080-32410402 / 22341782 Mail. [email protected] Mobile : 9845021409/ 9845372774 Web. www.apssm2013.com E-mail : [email protected] www.sassm.in International Symposium On Prostate, Androgens And Men's Sexual Health The 5th Pan Arab Congress of Sexual Health Jointly organized by the ISSM and ESSM April 18-20, 2013, Dubai, UAE June 20-23, 2013, Berlin, Germany Pan Arab Society for Sexual Medicine (PASSM) ISSM Executive Office 1 B Hassan Sabry St., Zamalek, Cairo, Egypt P.O. Box 94 Tel. +201222163858 1520 AB Wormerveer Fax. +202-24184645 The Netherlands Web. www.passm.org/Dubai2013/Welcome.html Tel. +31 75 64 76 372 Fax. +31 75 64 76 371 AUA Annual Meeting Mail [email protected] May 4-8, 2013, San Diego, CA, USA Web www.issmessm2013.org Headquarters: 1000 Corporate Boulevard XII Latin American Society Of Sexual Medicine Linthicum, MD 21090 Congress (SLAMS) Phone: +1 410-689-3700 August 28-31, 2012, Cancun, Mexico Fax: +1 410-689-3800 Mail. [email protected] Email: [email protected] Web. www.slams2013.org Web: www.aua2013.org 33rd Congress Of The Société Internationale D’Urologie (SIU)

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NEWSLETTER

Middle East Society for Sexual Medicine March 2013 – Issue 4

September 8-12, Vancouver Convention Centre, Fax +31 756 47 63 71 Canada Mail [email protected] SIU Central Office Web www.assmweb.org 1155 University, Suite 1155 Montreal (Quebec) 2014 Canada H3B 3A7 16th Congress of the European Society for Tel.: +1 514 875-5665 Sexual Medicine (ESSM) Fax: +1 514 875-0205 January 29 - February 2, Istanbul, Turkey [email protected] CPO Hanser www.siu-urology.org P.O. Box 1221 22882 Barsbuttel,Germany 21st Congress Of The World Association For Tel. +49 40 67 08 820 Sexual Health (WAS) Fax. +49 40 67 03 283 September 21-24, Porto Alegre (Rio Grande do Sul), Mail. [email protected] Brazil Web www.essm.org Web. www.worldsexology.org World Meeting on Sexual Medicine 2nd Biennial Meeting of the MESSM October 8-12, Sao Paulo, Brazil October 3-5, Cairo, Egypt ISSM Executive Office MESSM Executive Office P.O. Box 94 P.O. Box 94 1520 AB Wormerveer 1520 AB Wormerveer The Netherlands The Netherlands Tel. +31 75 64 76 372 Tel +31 756 47 63 75 Fax. +31 75 64 76 371 Fax +31 756 47 63 71 Mail [email protected] Mail [email protected] Web www.issmslams2014.org Web www.messm.org

Fall Meeting Of The Sexual Medicine Society Of North America (SMSNA) November 21-24, New Orleans, USA SMSNA 1100 E. Woodfield Road, Suite 520 Schaumburg, IL 60173, USA Tel. +1 847 51 77 225 Fax. +1 847 51 77 229 [email protected] www.smsna.org

2nd Biennial Meeting of the African Society for Sexual Medicine (ASSM) November 20-21, Durban, South Africa ASSM Executive Office P.O. Box 94 1520 AB Wormerveer The Netherlands Tel +31 756 47 63 72

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Become a member of the Middle East Society for Sexual Medicine (MESSM)

If you become a MESSM / ISSM dual member you will start receiving 12 annual issues of the peer-reviewed Journal of Sexual Medicine (JSM)

As a MESSM member you will have the following benefi ts: • Access to a network of professionals in the Middle East • Discounted fees for the biennial meetings and symposia • Access to the members only section of the MESSM website • Access to the committees • Biannual MESSM Newsletter • Vote at the Business Meeting

If you become a MESSM/ISSM dual member you will have the same benefi ts as MESSM membership PLUS: • Access to a network of 2000+ International Sexual Medicine Specialists • Free subscription to the Journal of Sexual Medicine (JSM, 12 issues a year) • Access to the members only section of the ISSM website • Access to the ISSM Discussion Forum (former ISSM list) for discussing vexing cases and problems • Monthly ISSM e-Newsletter

Please visit our website for more information and the online application form www.messm.org

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